Laserfiche WebLink
SAN JOAQIIIN COIINTV ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Convience Store <br />nn <br />FACILITY ID # SERVICE REQUEST # <br />di�C� ��� <br />OWNER i:Al3RA7gR <br />tai <br />cHEofcitD{(,�{{o_AaDAessCi <br />FAciLtry NAME <br />Fast N Esy #116 <br />PHONE # Ert- <br />SITE AnDRESS <br />1399 st,Qot um6�r <br />E. Yosemite sAe e. Name <br />Homi; or MAILima ADDRESS <br />Mant a <br />9z�536 <br />HOME Or MAILING AuDREGS (If Different from $Ile Address) <br />9lroat <br />u ba <br />S oot!! me <br />CITY <br />STATE zip <br />PHONE #1 <br />� 1 <br />APN ff <br />(JIRD USI; APPLICATION ft <br />PHONE 12 Ext• <br />( 1 <br />le134111, <br />BOS t)ISTRICT LOCATIoN CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQuasToRBon <br />nn <br />Die Garber <br />CNpCKIf 0 t, 1 1lyADDR655LG1 <br />Dusinvas NAME <br />k <br />PHONE # Ert- <br />ee Pump Company <br />( 209 ) 537-939Q <br />Homi; or MAILima ADDRESS <br />F� <br />FAX H <br />EMPLOYEE#: <br />DATE:tk- <br />�J .....� <br />( 209) 537-9398 <br />CiT�Ceres <br />_ <br />STATE CA. ZIP 95307 <br />13ILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized alwnt Of same. <br />noknowledgo that nil Rite and/or project Spcoitic FINVIRONN42laTA1. I'IRAr.TI; Dr--PARTMENT 1100dy ahorges assoeintcd with this project <br />or notivity will he billed to nae or Illy business as identified on this f'onu. <br />I also ccrlil'y thni I have prepared this appiioation and (lint (ho Nyork to bo perl'onnod will bo dmic in accordance with all SA;\ JOAOI:IN <br />C011NT)' U)ziitroWl, C'ocfes, .5%inulaliis, STAW and Fpl)rRAI, laWS, <br />APPLICANT'S SIGNATURE( <2 . 0 <br />PROPERTY/11ISI,NE."OWNFRO OPERATOR F ANA,%,HR 1,-I OTIIE42tkUTHollizEDt1GP:Y1'® Seryi e get <br />Ir.�1Pt'LlC.4N1' fs no! the BILLIMO PANT); proof of authorisation to sign Is required 771le <br />AUTHORIZATION TO RRLEA�E INFORMATION. When applicable, I, tho owner or operator or the property 1Ocated nI the <br />abovo site addm4s, heroby authoriza the rcloasc or any and all results, geotechnical dnla and/or onvironnientalhite tlStiosxnnew <br />inforlllntion to the SAN .IOAQVIN COIJ.4TY I51viwm4ENYrAL HRAim-i DF.PART.�VfiNT ASS0011 as it is itvOilable ant( at the sn11 it i, <br />provided to me or niy representative. R 71 <br />TYPE OF SRRYIoR REQUESTED: <br />%�s, <br />COMMENTS: <br />L-10 <br />^ <br />44"0, J Q, <br />(12130115) Replace Veeder Root annular sensor <br />k <br />Fa,��,4MY <br />F� <br />A00&P7ED BY: 5 <br />EMPLOYEE#: <br />DATE:tk- <br />�J .....� <br />AesiaNeo To: <br />EMPLOYEE; #: <br />DATE; 3c� <br />Date Service Completed (if already completed): <br />SERVICECODE: <br />PJ <br />Amount PO' 7Sd.� Payment Date <br />Pea Amount: 3g� :_./fi <br />le134111, <br />Payment Typ volce 6 Ch # 630,11 <br />Rec (ved 13y: <br />EHD 4802.025 GR FORM (Golden Rod) <br />REVISE011117/2003 <br />